| Co-payment |
Mechanism, in which it is mandatory for the patient/insured/user to bear part of the costs of health services at the time of use. This mechanism of mandatory direct participation in costs has other denominations, such as moderating rate, participation in costs (cost-sharing), co-participation or user counterpart27. Fixed rate imposition for each medical service, introduction of a variable rate representing a percentage of the total cost of a service, combinations of fixed amounts and percentage rates or “annual deductible” system, i.e. setting a minimum annual level for medicine or service expenses per patient, below which no reimbursement is granted. System mainly used in private insurance. |
State cost reduction: Transfer costs to the user. Increasing inequality: Increased out-of-pocket spending, leading to reduced access to promotion and prevention measures; worsening in treatment adherence; waiver or postponement of the use of services, especially by the older adults, chronically ill and low-income people; and increasing social inequalities. Cost increase in the medium and long term: Additional administrative expenses and higher subsequent costs with less health. |
| Privatization mechanisms |
Three main mechanisms: promotion of the State for the expansion of the private sector (purchase of private services by the State, encouraging the participation of private entities in the management of resources and provision of services), tax exemption for users of health plans and private services. |
State cost reduction: Transfer of costs to the private sector and increased competition. Increasing inequality: Provision of differentiated services related to access and quality. Cost increase in the medium and long term: Increased costs of high technology or deprivation of those that cannot afford access to available technology. |
| Decentralization |
Subnational or local governments assumed greater responsibility with the planning, budgeting and execution of public health activities. |
Central government cost reduction: Transfer of costs from national governments to subnational and local ones. Although it reduces the distance between the population and immediate managers, expanding the pressure power of users, it reduces the responsibility of national governments and their financing. Increasing inequality: Differentiated treatments in terms of quality and availability, according to different possibilities among regions and localities. Cost increase: Loss of economies of scale in purchases and public procurement. |
| Segmentação |
Subsystems with different modalities of financing, affiliation and provision, each of them “specialized” in different strata of the population, according to their labor insertion, level of entry, ability to pay and social class. One or more public entities coexist, social insurance and several funders, guarators and private providers. |
State cost reduction: Transfer of costs to the various funders. Increasing inequality: Worsening of the inequality in access and quality of services between different population groups. |
| Fragmentation |
Coexistence of non-networked units and services or establishments that do not mutually cooperate, ignore and/or compete with other providers. Multiple agents operating without integration prevent the standardization of content, quality and costs of service provision. Generates increases in transaction costs and inefficient allocation of system resources. |
Cost reduction: Exemption of the State from the provision of the public service. Competition among service providers. Increasing inequality: Reduction in universal access to the health service, lack of coordination increases the risk of some segments of the population being discovered, loss of solidarity of the system accentuates segregation of groups of the population and inequalities in access and use of services. Cost increase: Inefficient transaction and allocation costs generate larger resources. |
